Provider Demographics
NPI:1497723894
Name:BALMER, LAURA (CRNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BALMER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 MEADE ST
Practice Address - Street 2:SUITE L3
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1813
Practice Address - Country:US
Practice Address - Phone:570-723-2855
Practice Address - Fax:570-723-2877
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303540-1363LA2200X
PASP013789363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02301004Medicaid
NY02301004Medicaid
NYDD2571Medicare ID - Type Unspecified